Placenta Service Contract

Name*

First NameLast Name

E-mail

Phone Number*

Area CodePhone Number

Secondary Phone - This is a number the courier can call when they arrive for pickup. New mothers are often unavailable for answering the phone at this time, so a secondary number is handy.

Area CodePhone Number

Estimated Date of Delivery

Date

Planned Birth Location

What is the best address for the delivery of your final product?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

How did you hear about us?

Photography

We sometimes take photos of Placentas for record keeping or education. Identifying information is never shared. Do you give permission for photos of your placenta to be used as described?

Agree*

Yes i agreeI do not agree

Acknowledgements

Ahana Birth Services, LLC is not a licensed medical professional and does not diagnose, treat, or prescribe for any health condition. No specific benefits are promised and benefits have not been evaluated by the FDA. It is your responsibility to determine if using placenta preparations may be ofbenefit to you. Placental supplementation is intended solely for ingestion by the individual who has birthed the placenta(s).

It is your responsibility to discuss release of your placenta from your place of birth. Your placenta should not be treated with alcohol, formalin or any other perservative. If it is, it is nolonger eligable for encapsulation.

Agree*

Yes i agree

Please initial the following:

If either mother or baby develops an infection at the time of delivery or within the following 24 hours after delivery -it is important to let us know. Initial that you will notify us within 24 hours if an infection is diagnosed. (Please note, a positive GBS status is NOT an infection, however if you let us know at the time of delivery that you have tested positive, we are happy to process your placenta using the traditional method regardless of your original situation.)

Initial Here*

Please initial the following:

I understand that i am responsible for storing the placenta on ice or in other refrigeration, calling for pickup in a timely matter and having someone available to hand the placenta to the courier when he/she arrives. We cannot refund if the placenta was not on ice/ refrigeration for more than 2 hours or if you fail to contact us concerning pickup. You are responsible for any extra courier fees due to wait time at the pickup location.

Initial Here*

Is there anything else you want us to know?

I have read and understood this agreement, including the terms and conditions, and agree to be bound to them.

Signature*